Intestinal graft-versus-host-disease staging by video capsule endoscopy

Graft-versus-host disease (GvHD) is a leading cause of morbidity and mortality in patients who have undergone allogeneic bone marrow or peripheral blood stem cell transplantation (BMT/PBSCT) [1]. About 20 – 50 % of patients who have received BMT/PBSCT develop symptoms of acute GvHD [2]. GvHD most often affects the skin, liver, and gastrointestinal tract. In severe intestinal GvHD broad ulcerative lesions develop, leading to diarrhea, malabsorption, intestinal hemorrhage, and sepsis [3]. The gold standard in the diagnosis of intestinal GvHD is upper and lower gastrointestinal endoscopy with histological validation [4].

A 57-year-old woman with acute myeloid leukemia who had recently received a PBSCT from an HLA-identical sibling suffered severe hemorrhagic diarrhea. The symptoms started 12 days after the transplant. The diagnosis of GvHD was histologically and endoscopically confirmed by sigmoidoscopy (CF-H180AI/L; Olympus Co. Ltd., Tokyo, Japan) ([Fig. 1]). Esophagogastroduodenoscopy did not reveal relevant pathologic findings.

Fig. 1 Endoscopic appearance of severe diffuse hemorrhagic inflammation of the sigmoid colon.

Since the patient’s condition rapidly deteriorated, a total colectomy was discussed as a last therapeutic option following the failure of several immunosuppressive drug regimens including corticosteroids, cyclosporine, mycophenolate mofetil, pentostatin, infliximab, and antithymocyte globulin. Video capsule endoscopy (PillCam SB; Given Imaging Ltd., Yoqneam, Israel) carried out to evaluate small-bowel involvement in the GvHD revealed continuous severe hemorrhagic inflammation of the entire small intestine starting from the proximal jejunum ([Video 1]) and ending in the terminal ileum ([Video 2]).

Video capsule endoscopy proved to be a successful minimally invasive diagnostic method, accurately visualizing the involvement of the small intestine in severe GvHD, obviating the necessity for diagnostic surgical exploration in a clinically unstable patient.

The patient died of multiorgan failure due to GvHD. Histological analysis of the intestine confirmed severe GvHD involving the entire small intestine and colon ([Fig. 2]). We conclude that video capsule endoscopy is suitable for staging intestinal GvHD especially in those patients unable to tolerate invasive diagnostic measures such as double-balloon enteroscopy or surgery.

Fig. 2 Histological section (H&E staining) showing autolytic mucosa of the small bowel with acute fibrinous and chronic inflammation. Pronounced submucosal edema and dilated capillary vessels due to graft-versus-host disease.

Video 1 Sequence of video capsule endoscopy of the proximal jejunum showing severe hemorrhagic mucosal inflammation and broad ablation of the mucosal surface.

Video 2 Sequence of video capsule endoscopy of the ileum with large amounts of intraluminal blood due to severe graft-versus-host disease.

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References

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• 2 Remberger M, Persson U, Hauzenberger D. et al . An association between human leucocyte antigen alleles and acute and chronic graft-versus-host disease after allogeneic haematopoietic stem cell transplantation.  Br J Haematol. 2002;  119 751-759
• 3 Martin P J, McDonald G B, Sanders J E. et al . Increasingly frequent diagnosis of acute gastrointestinal graft-versus-host disease after allogeneic hematopoietic cell transplantation.  Biol Blood Marrow Transplant. 2004;  10 320-327
• 4 Cruz-Correa M, Poonawala A, Abraham S C. et al . Endoscopic findings predict the histologic diagnosis in gastrointestinal graft-versus-host disease.  Endoscopy. 2002;  34 808-813